The Nonprofit Leader's Guide by Boundless
We want to bring you the thoughts of some of the most impactful leaders in health and human services. Their real-world experience in driving growth and impact and leading in hard times might be just the extra dose of motivation and common sense you need to bring to your organization whether you are an Executive Team member or the Board President. We think that leading the conversation about the nonprofit business sector and what nonprofits should think about now is part of our mission, “Building A World that realizes the boundless potential of all people.”
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The Nonprofit Leader's Guide by Boundless
From Survive to Thrive. Integrated Health Care Strategies to Implement Now
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Fragmented care doesn’t just waste money, it changes lives in the worst ways. When primary care, behavioral health, dental, specialty services, and social supports don’t communicate, patients with complex needs get bounced between systems, families burn out, and preventable crises become “normal.” We sit down with leaders from Boundless, HealthPort, and Woods System of Care to ask a sharper question: what if integrated care models aren’t failing, but alignment is?
We compare how whole person care actually works on the ground across very different settings: an integrated health center designed around disability and complex needs, a rural Certified Community Behavioral Health Clinic (CCBHC) with vertically integrated services, and a population health network serving individuals with intellectual and developmental disabilities, autism, acquired brain injury, and complex medical conditions. Along the way we dig into care coordination, one-stop shop clinics, same-day access, peer specialists, transportation, “food is medicine,” and why patient engagement often depends on details like sensory rooms, intake design, and trust-building that starts before the first appointment.
Then we get honest about the blockers: misaligned incentives across Medicaid and state policies, “partnership theater” without shared accountability, and the data challenges of proving total cost of care savings when funding flows through multiple channels. We also talk about what’s hardest to anticipate, including unifying programs under one EHR and building a workforce development engine strong enough to sustain integrated care at scale.
If you care about accountable care, integrated behavioral health, population health management, and practical strategies that reduce ER visits while improving quality, subscribe, share this conversation, and leave a review. What would it take for patients in your community to truly experience whole person care?
Welcome And The Alignment Question
SPEAKER_05Welcome everyone to another episode of the Nonprofit Leader's Guide brought to you by Boundless. I'm your host, Scott Light. Healthcare leaders are hearing the same messages out there, whether it's from CMS or Medicaid, payers, and communities, and it's this the future of healthcare is accountable, it's integrated, and it is whole person care. Yet despite years of investments in value-based care, behavioral health integration, care management, the social determinants out there, many organizations still struggle with a fragmented experience for their patients. There is inconsistent engagement and also limited population level impact. Today's discussion explores a really important question. It's this What if the challenge isn't the model itself, but the alignment required to make the model work? We're going to dive into that very question and plenty of others with a terrific panel of guests here. Let me introduce you to them right now. Katie Babcock is here in studio with me on the Boundless Campus. She is State Director of Clinical and Community Services. Dimitri Kavathas is here, Chief Executive Officer at Healthport. Teen Hansen Turton is here as well, president and CEO of Woods System of Care. And Dr. Silaja Moonsonori is here as well. She is Chief Medical and Clinical Officer and also VP of Integrative Medicine at Woods System of Care. Welcome to you all.
SPEAKER_02Thank you for having us. Thanks for all to be here.
SPEAKER_05I'd like to go around the horn. Let's let's let's talk a couple of level sets here as we get started. I'm sure all of you have heard uh this quote. When you've seen one integrated care model, you have seen exactly one integrated care model. So let's take a minute or two. Katie, why don't you start us off?
What Integrated Care Looks Like
SPEAKER_05Describe the model of care here at Boundless. And then the the layer to that is um how is that model going to evolve as you see it?
SPEAKER_01Boundless has intentionally expanded from being a disability services organization, offering residential services into what we think of now as a whole person care organization. So today we're integrating all health services: primary care, psychiatry, dental. We have care coordination, center-based educational services, and residential care. And our biggest focus is really connecting all of those services around the person with them being at the center of it. Practically, for us, that means we run an integrated health care clinic with many of those services in it. And we also integrate behavioral health into all of our service lines. We're also integrating that care coordination into every one of our programs. So making sure we have really a single point of contact to access all the different types of care that we know an individual needs, whether that's with us or with our partners.
SPEAKER_05Okay. Uh Dimitri, tell us about Healthport.
SPEAKER_04Healthport is a certified community behavioral health clinic in the rural part of the Maryland Eastern Shore. It's the breadbasket of the Mid-Atlantic. Uh cover four rural uh areas, uh, providing primary care, behavioral health care, which includes medicated assisted treatment, supported employment. Uh we have a food is medicine program as well as uh a housing program, which includes residential, supervised beds, and supportive housing as well.
SPEAKER_05Okay. Umaja and Teen, tell us about Woods system of care.
SPEAKER_03Sure. So and actually Woods uh system of care is over 100 years. In the last 10 years, we have transformed ourselves into a population health network, and we're now called the Woods System of Care, with over 21 affiliated and nonprofit and other agencies that make up the system of care. And we have over 200 programs and serve about 40,000 individuals across Pennsylvania, New Jersey, and a little bit of Delaware. Uh, we serve individuals across the lifespan with intellectual and development disabilities, autism, acquired brain injuries, and other neurodiverse issues, along with individuals with behavioral health conditions, complex medical and genetic conditions, and also other complex care needs. So think of us as the organization that really addresses complex care needs for individuals. Now, our system is unique. You'll hear more about it because we really are integrating all of the services, whether it's education, you know, early childhood education, primary and health specialty services, behavioral health, residential and in-home services, vocational supports, case management, crisis services, and community-based programs all under one umbrella. And the care, as you'll hear more about from Dr. Mousaneri, is delivered by an interdisciplinary team from amazing 24-7 caregivers to teachers, physicians, psychiatrists, nurse practitioners, nurses, behavioral health specialists, dentists, therapists, and many other case managers. I think the key for what we do and what we've evolved into is that we are connected through a population health framework and a lens coordinating care around the individual throughout all stages of their life. And that's really what makes us innovative. But I also think it's where the direction needs to be for especially the populations that we serve and the complex care needs. And maybe Dr. Mousanea can talk a little bit more about our clinical side of what we do.
SPEAKER_02Thank you, Teen, and thank you for the question. Um, just like Teen mentioned, our model we created to address the complex needs of the individuals with the intellectual disabilities and autism, but it can be replicable to any specialized population. Um, in the traditional system, the providers were not communicating. And so that's why we created this model where we serve all the individuals at any level of care at one place, one stop home. And there is integration between the speciality services, primary care, behavioral health, care coordination, and it's the interdisciplinary model that carries it across the lifespan through the transitions and the caregivers and families feel that this is really applicable to the whole person model, not just during the visit.
CCBHCs And The Policy Tailwind
SPEAKER_05Let me ask a readiness question. And Dimitri, why don't you start us off here? From your perspective, what are healthcare leaders getting right? And maybe what are they still underestimating about the transition to accountable whole person care?
SPEAKER_04Well, for me, what's really exciting is I think we're in a new revolution in behavioral health care, and that involves the certified community behavioral health clinic model. Um, this is really the clearest expression of direction from the federal government in quite a long time. And there's now over 500 CCBHCs across 46 states that are growing, and the payer systems, which include CMS and the state Medicaid agencies, are actively really signaling accountable whole person care. Um they've included new policies to fund these services. There's the enhanced rate that occurs from this, uh, which is a prospective payment model. And, you know, this is extremely exciting because the federal government is now putting over $300 million a year just to make this happen across the country. And then you have private foundations like the Balmer Foundation putting in over $70 million to expand it in Michigan, Kansas, and Illinois. So this is a really exciting moment.
Funding Misalignment And Payment Models
SPEAKER_03There's no doubt. Totally agree with the Mitrix that our system is moving in the direction. However, we find that, you know, some of the regulations, the funding or the incentives are not actually aligned everywhere, certainly around the CCBHCs. That's a wonderful model, the FQHCs, the hospitals. But if you take a systems approach, which is what we have at uh the Wood System of Care, uh, we're not a traditional, you know, the system as a whole, you know, we have two CCBHCs, but that's you you can't reach, you know, two states with that. So we created, I think, a system that parallels. Uh, and in those systems, uh, you know, the incentives are not aligned, so misaligned. So it really requires organizations like us, and we do that through affiliates, to have a very creative way to do revenue cycle management, weaving funding together if it's not there. So I would say that our federal government, our state governments, accounts still have far to go to aligning all of you know the funding streams around this whole person care and not just one program. And I think that's a challenge we always have in the United States. We like to sort of put a little bowl around programs. Uh, there are other models out there, the PACE, uh, the persons for all inclusive care is a fantastic model, which is a per member per month model, it's been around for more than two decades. And we've always said that take that model government, you know, CMS, we talked to CMS and others in states, take that and make it what we saw pace light for, for example, for a population that we sort of have intellectual disabilities, autism, uh, and neurodiverse challenges. But we're not there yet. So that's why, you know, organizations and leaders like all of us here in this podcast, I think, all have that sort of policy lens. How do we push a government? We're totally agreeing where they're going, but let's make sure that, you know, also the funding streams and all is aligned throughout the system, including to say service providers and uh folks like us that don't quite fit into one model or the other.
SPEAKER_01I would agree. I think it can't be a one size fits all. It has to be a system, especially in today's kind of ever-changing and complex funding world, it has to be a system that has shared goals and a shared vision for what we need to create around the person, but it has to be able to survive funding changes and staffing changes and system changes. And so I think figuring out in this new era, I think we all are figuring out how do we build care models that actually are a new way of doing it and that generate the outcomes we want to see. I do think, though, that Dimitri, right, every signal is pointing towards greater accountability. I think that government and state organizations are continuing to encourage integration. They're continuing to encourage accountability for good outcomes, not just for providing a service, but for actually affecting change in people's lives.
SPEAKER_02I think what we are seeing, the uh IDD artism, they are presenting with multiple medical and psychiatric complexity. They are not straightforward. So you need multiple providers and specialists, and really you need an integrated model to see that outcomes that what Katie was referring to. Um otherwise, we are spending um extra money on the high acute need, which is like hospitalizations, emergency room visits. Um the most cost-effective and quality care model is the integrated care model.
SPEAKER_05Dr. Munsonari, um uh let me ask you a follow-up there. When when you talk to your peers, do you do you say, hey guys, this this integrated model, this is not an option anymore. This is absolutely essential. Is that the way you look at it?
SPEAKER_02Yes. Um I totally agree that this is the model we need to thrive in towards. Uh, like I said, this is just not for the IDD autism population, but any comorbid conditions. Today we are seeing an interconnected need. Um, and when we look at the person as a whole, we are not going to separate primary care, behavioral health, and specialist care because they are coming up with multiple comorbidities, such as seizures, is such a high comorbidity with this population. So you need a connection with the neurologist and a GI person, genetics, all these things, they play a role in the whole person care. And also now the care is so fragmented that the important information can be missed. You know, one simple example: a person can be having like an ear infection and goes to a primary care and gets an antibiotic, but rest of the people may not know. And when they reach a psychiatrist, this is my example, that they think, oh, the behavior is worse. We need to increase the psychotropic medication. So, as a practicing psychiatrist, I always feel bad that we are increasing medications without consulting the primary care and the specialist services. So I feel that to improve the quality of the care, the integrated care model is essential. And especially the communication, collaboration, that interdisciplinary approach is the critical part.
SPEAKER_01Agree with that.
Integration Requires Culture Change
SPEAKER_01I think integrated care really is a change management exercise. It is changing the way people think about their jobs, it's changing the way we think about productivity and delivering service. Traditionally, there's been a lot of staying in your lane. You're seeing a patient right here in this moment, you're solving a problem for them now. And I think we're really moving towards, like you were saying, needing to communicate. So I think the technical work can be difficult in building these systems and ways to communicate, but the people work is just as hard in kind of reframing what delivering that care means.
SPEAKER_03And also add, like, you know, when it comes to care for folks with intellectual disabilities, autism, neurodiverse issues, overall healthcare providers or system is sort of behind. I mean, I'm embarrassed to say that I spent most of my career before coming and joining and leading, you know, Wood system of care a decade ago. I spent it in the healthcare industry, and I was so proud serving vulnerable populations with comorbidities, uh, both in the US and uh globally, never to really realize the complex nature of people that we serve that have you know neurodiverse issues. So I think our system on the provider side really needs to be trained up. Um, we and we take it upon ourselves at Wood System of Care, and Dr. Mojinaire is amazing. She trains really hundreds of next generation providers. We have something like 25 uh clinical um, you know, networks with universities and others where we train physicians, nurse practitioners, hospitals, et cetera. And we need more of that. We need our healthcare system to, I think, really get ready for serving the complex care people that are there and will only grow over time. Because other than that, even no matter what you do, even with an integrated care model, if you do not have providers at the community level that understand the challenges of the population, what their needs are, et cetera, the uniqueness, as Dr. Mussonari says, we're not going to be ready to serve that very complex population. And the people we serve will continue, uh, at least the ones that are not served by us, will continue to go to the emergency rooms, hospitals, and actually be high cost utilizers of the healthcare system, mainly because our provider network that's out there is not ready. So we have a lot to do also on the education front when it comes to readiness for serving complex populations and doing the whole integrated and whole person care in the United States.
SPEAKER_04A vertically integrated model is one of the great things about the CCBHC model. And, you know, for us, for example, at health court, we have a 13-dimensional model that's vertically integrated. So we have housing services, primary care services, mental health care services, addiction services. We have a medication adherence program where we use medicurance technology to manage people's medicines so we know if they took it or not, which is extremely important. If you don't take a medication at least 80% of the time, no matter what it is, it doesn't work. So we have an understanding of people are taking the medicine or not. We have population health management, we have employment services, we have financial management services with representative AE services, we have a transportation fleet of 98 vehicles to get people around. We have a focus on community integration with psychiatric rehab day programs, we have a food security program with a food is medicine, we're feeding over 700 people every day. Uh we have a crisis stabilization program, we have an eight-bed crisis services program, we have a 24-7 on-call on-site response program, and we use flexible funding through our um 340B pharmacy program to help clients get through their lives. So what's really exciting is that the alignment that has occurred in CCBTs and the understanding that the prospective payment model, where you have cost plus care, is allowing these new innovative things that will focus on people that need the most. We're really thrilled. And uh just for you know clarity, I am a board member of the National Council for Mental Well-being. This is like our big project initiative to make this a standard across the country. And there's significant commitment. The states are all jumping in at 46 states now. Uh, and you know, I just think that this is a thing that we could all use to build off on to make our healthcare system so much better.
SPEAKER_03But I would say with Demitris, you are in a state that has uh embraced that. So if you take a state like New Jersey, uh you've got, you know, the the original you know, CCBHCs that has the prospective payment, just like FQAs, federal qualified health centers have, the others don't. So you they're relying on a grant that are now running out at the federal level, et cetera. So I think that you know the states really need to look at, you know, there's no doubt, you know, the FQHCs were the first to start it. I mean, I we're huge fans of the CC BHC models, but it really has to be supported the way that you're talking about. Now, within the Wood system of care, we absolutely have, you know, the education funding, we have housing funding, we have uh we also do the waiver services, et cetera. And that's how you said it beautifully. We are weaving funding, you are weaving funding to make this work. So we have to weave that funding very differently. We don't get we have to negotiate our own rates with the managed care organizations. We do that all the time. We have several uh value-based contracts with MCOs and managed care organizations that have seen that as a need. However, it's not consistent across states, it's not consistent about counties. And I think that's a challenge where at least the federal corporate health system, which is a parallel system to the CC BCs, have done it consistently and it's rolled up the same way in the states. I think that goes back to sort of the systems question around we need to get, you know, we need to get our friends, the CMS, at the federal government, and our states to really realize it.
SPEAKER_01I agree. A big thing we are focused on right now is gathering data about the populations that we serve and how much it actually costs to care for them and then comparing that to the total cost of care if they were not engaging in our primary and preventative services to be able to advocate for that funding. Because you're right, it's not, it's not equal across the board. It's not um, you know, we don't all have the opportunity of the C C BHC model, which is amazing, but we have to make sure that that is equitably across the states and that we can utilize that because it's a huge issue to figure out how to pay for the services we know that people need.
SPEAKER_03This is a great point. And we we worked a little bit with CMS for a few years looking at our data across the two states, our very complex individuals that we serve. And we also had uh a value-based, still have a partnership with one of the uh MCOs on the Medicaid side that happened to be the blues. Uh, in and uh we we know that the care that is provided by uh a clinical team with Dr. Mochonaire and her team saves uh roughly 25%, uh, you know, of which is what exactly where you want to go. However, I go back to because we're not, you know, a traditional provider where somebody's looking at, oh, Wood System of Care saved uh, you know, Pennsylvania, New Jersey to 25%. It doesn't get captured. And that's where I go back to is that that, you know, I think especially on boundless and wood system of care, we're doing a lot to support the direction where the country is going, but our, I don't think our data is actually being captured because it's three or four different, you know, funding agencies at the state level that actually gets to get the credit. But really where the credit needs to be is showing the cost savings, special on the Medicaid Medicare spend, which is you know the high spend usually for complex populations. So I gotta go back to we we still have to align all this stuff, which is why we love the CCBC model, but there's more to it. And I think our policymakers really need to figure out how uh you do this the right way. And so agencies like us can really prove and demonstrate to them and get the credit forward and maybe some value back so we can continue to grow and expand uh and scale what we're doing at the community level.
One Stop Clinics And Home-Based Care
SPEAKER_02Coming from the clinical standpoint, we work so hard in really looking at one person and creating that model where we save, uh, just like Teen said, um, you know, minimizing the acute care utilization and also serving them at the community level. That's the most important thing, where they are, where the person is. It could be, you know, via telehealth or in-person appointments and with pushed-in services, you know, we are creating um a kind of like a pseudo clinic in their home that they are able to access. One another thing we do is creating that one-stop shop model. You know, we can say that um when they come to the clinic, because for this population, navigating multiple appointments and also going for ancillary services, think about going for blood work. That's a nightmare for a family to take the individual who has transportation difficulties and who has significant anxiety about the blood work, you know, and dental care. You know, sitting in that dental chair, getting the hygiene, a six-month hygiene checkup done is a lot. So that's what we are trying to do at Wood System of Care, creating that model weight, they come once and then everything is taken care of.
Designing For Patient Engagement
SPEAKER_05This is really good as we're talking about patient engagement here. Let's expound on this a little bit more. And and Katie, question for you. Um, when you look at the the workflows and everything that that's that's going on here to increase patient engagement, um, how are you building that environment here? We were just talking before we started recording that, you know, the arrows are pointing really up for dental services here. I mean, you're seeing some real engagement and and patient satisfaction and terrific outcomes. So talk about that in terms of patient engagement here at Boundless.
SPEAKER_01I think the biggest barriers, like we've been talking about, everyone has kind of alluded to, for our complex patients, are often things like transportation, stable housing, just navigating an extremely complex system. And then for individuals with IDD, you have an added layer. You have different sensory needs, communication differences, you have guardianship, you have a lot of previous negative healthcare experiences, all of those you're bringing with you to that first appointment. And so I think it's really about two things. One is creating an environment when they come to access care that acknowledges all of that, and then creating a system of care in your community that can support it. So on a small scale, that's things like having a sensory room on every floor of our clinic, it's having dimmable lights, a centralized, easy intake. And on a larger scale, it's interacting with our community, like we've been talking about as well. So we're offering training to our first responders, especially those who respond in areas where we have high acuity programs. We are partnering with specialty providers. Um And actively again trying to collect the data that shows the outcomes that we are getting and being able to tell that story to increase funding for our population as well.
SPEAKER_05Well, you hit on several things there. The the micro and the the macro. I can remember when these facilities were being built here and there were real serious discussions because these things matter. There were real serious discussions about what the paint colors would be, because you want paint colors when people walk in to soothe and you know to bring the shoulders down, not up, right? Right.
SPEAKER_01Yeah. Thinking about the environment people experience, and I will give credit to our chief strategy officer who says this on every tour, and I steal it from her, is that a lot of spaces are built for the general public and people with disabilities are welcome. But our integrated health center is really built for people with disabilities or complex needs of any kind, complex behavioral health challenges, and the general public is welcome there as well.
SPEAKER_05Okay. Dimitri, how about the those micro and macro factors? Uh, can you talk about a few from your perspective?
SPEAKER_04Oh, yeah. Oh yeah. This is something that's really passionate about.
Same Day Access Plus Peer Support
SPEAKER_04Uh, you know, one of the great things about the CCBHC model is same-day access. And I mean someone can walk in, we engage them immediately, we triage what they need, and then many, many, many moments get people into care immediately on the same day. If you think about the wait lists that are around this country to get care, it's horrendous. And for us, you know, and for the model, same-day access is a moral commitment. It's not an operation metric. This is something where we need to engage people immediately. If you think about people that are struggling with mental health or addiction issues, timing of engagement is the most critical thing to have success. So if you can have people get immediate attention at the time and moment when someone needs it, it's a critical moment for that person in their recovery. So when we talk about outreach and engagement, you think about a consumer-centered design. Like what do people want? They want care when they want it and when they need it. And having, for example, for us, we have a consumer advisory board. We have clients, active clients that are full-voiced voting members of our board, that gives us guidance on how do we engage people, how do we understand what people want and need? How do you engage and integrate peer specialists, people that have lived experience in the system embedded in every single program? So they understand what people want and need. And when clients see that, they understand wait a minute, there's a person right there that had my experience, and that that person understands what I need. And you know, unfortunately, not always all of our staff have that kind of ability to make that message occur. But when you embed peer specialists, that is the way to go. So when you think about outreach, right, you're thinking about people coming to you from referrals, but it's really about engagement from when family members are needing help, when family members are reaching out for their loved ones to get help. How do we get people to where they go? We go pick them up. We have a fleet of people to go get them. And then in that process of engaging people, we really nudge the whole life. We talk about not just what the problem is in front of them that they're focused on, but what are these other things that you need? What is the kind of engagement you need to solve these other issues that are impacting your recovery? And you know, for us, one of our biggest investments was a weekend team. So we have seven-day week programming, day and night, where people can get engagement whenever they want. And that so if someone has a job, but they don't they want engagement for the weekend, great, come on over. We'll come get you too, whatever you want. So, like this whole same-day access philosophy is really one of the most important things, I think, for the system of care that we're all engaged in.
SPEAKER_03And
Adapting Care To Local Needs
SPEAKER_03I would say that, you know, we serve, you know, we serve two states and we're in every single county in New Jersey. So we that means you serve urban areas, rural areas, more suburban areas. While the models stay intact and the whole person integrated care model that Dr. Mochiner, you know, talked about stays in intact in the whole throughout the system. The service, um, the services are different depending on the needs. So, for example, two of our affiliated agencies use mobile vans uh and uh that to bring services into the rural areas because there's not providers there, et cetera. And then we connect them back to the system. Uh in some of our areas in New Jersey and also Pennsylvania, uh, we know we do opening centers can be very costly. We we create partnerships with hospital systems. We have a wonderful hospital, you know, a partnership with Audible Vonnabus in New Jersey, where we have an integrated primary and behavioral health clinic right in the Hamilton Medical Center, which is an area where we have a lot of group homes and another agency that provides services. Uh, so we are so that's an access. So I would say a model changes depending on what people are, et cetera. And I think that's the system too, being adaptable and figuring out what people are, what the communities need, and then creating different kinds of models. But the core of the model is still an integrated care model that focuses on that whole person. And that doesn't change, but the partners might slightly change and also the locations might change. And you said it, coming to people or doing telemedicine, we need to bring care to people where they're at, and especially in areas where they don't usually traditionally have a lot of access to care.
SPEAKER_02The families often think about only reaching out to the provider when there is a crisis or for an immediate issue. So educating the families and really engaging them in that conversation that preventative care is as important as seeking really medical attention when you need it. It's the mindset that has to change. And also, you know, care coordination, just like Dimitri said, you know, going into the people and really educating them and engaging them. They have been through these fragmented systems already multiple times. They are exhausted, they're tired. We need to build that trust back again into the integrated model. The only way we can do that is engaging them into that conversation, that we are here to help. We take care of the whole situation, whole person, and also building that network where they can have that access.
Why Integration Breaks Alignment Gap
SPEAKER_05We've all seen some of the findings from the Camden coalition. And one of them was something that they called the alignment gap, where organizations, again, may share all kinds of goals, all kinds of uh, you know, ethics and morals, everything, but they still fail or still come up short to coordinate effectively. So, broad question for the group why is integration so hard?
SPEAKER_01I think that organizations often share the same mission, but not the same workflows or funding, kind of how Teen had alluded to earlier. It's it's easier in theory than it is logistically and operationally to execute. And it's different community by community. And people in today's day of AI and Amazon and ease of access and so many things in our lives expect care to be and it should be, not reactive, but personalized and specific to that community.
SPEAKER_03And I would add that, you know, it's it's in even even we what system of care the uh the entities are all affiliated, which means we have a common, we are partners uh and we have, you know, bought into a shared purpose, uh recognizing that one organization can't do it alone. Uh and I think also, you know, we are the leadership, the culture and values are all aligned. I think if you're on the same path, uh, you know, and you all if you focus on what's the best way of serving the individuals that are part of the system, you can come far. But there is such a thing as uh because in my former chief strategy officer role in another agency is that culture eats strategy for breakfast, lunch, and dinner and more. So I think that the culture piece uh is important, but it's not end all be all. It is about how organizations come around that value, having trust and working with one another. And it is easier to do that if you're part of a system. And and the affiliation structure that we have, and I think we all have on this uh podcast, works well that way because we're aligned for the for the common purpose. I think we're slightly altruistic. We we're excited about building a care system around people, but we're also partners and we're also connected legally as an entity, even though we might be 14 or 21 entities. It works that way. And that goes to, I think it works very well when there is a that's shared leadership across organizations that come together under one umbrella.
SPEAKER_02Just to add on, it's about the right partners. What teen mentioned, the 21 plus affiliates, it's about really bringing their expertise and leveraging it to the whole system of care. So um it could be the you know, having that partnership with a major hospital or another managed care organization or an academic institution, really pulling all the pieces together towards that shared mission.
SPEAKER_01I agree. I think, especially people with IDD, one kind of one unmet need or one area can really be a domino effect. And so you have to have organizations to partner with across that entire system of care. And no one organization can do every single thing excellently. And so you need to be able to, yeah, have candid conversations and partner with other organizations across the country to figure it out. And we're building a new way of offering care. This hasn't been done. This is not the way that things have always been done. And I think as we enter this new era, having those partnerships is going to be critical.
SPEAKER_04I mean, I think there's a lot of partnership theater out there. We all see it. And I think that, you know, having an MOU doesn't necessarily mean anything. And we've all experienced that as well. And part of it is all about the shared accountability, shared outcomes. And, you know, a hospital wants to discharge people, you know, to you know, meet their requirements with CMS or um housing providers, they want stability, payers want to save money. Um, the shared metrics aren't there. I think governance without teeth is a real problem. And so, like for us in Maryland, we're really focused on our we have a really great health information exchange backed data infrastructure called CRISP, the Cheswick Regional Information System for Patients, horrible acronym. And uh they have just an amazing amount of data that shows cost savings across the system. So everyone's in it, all pairs, it's an all-payer model. This ahead, it's called the ahead model. This model is getting distributed across the country. So there's 10 states that are going to be diving into it as well, which makes me feel very optimistic about it. And I just think that this whole issue around alignment in particular and shared metrics is a really important piece because if you don't really have any kind of um you know shared data, like this HIE, for example, and shared dollars, um, you know, if we're saving money for the hospital, we're saving money for the system, the public behavior health system, then that's recognized as a value. Um, and then a shared plan, a shared treatment plan, right? Then it's really in the end, just a photo op, right? We're just not, you know, really working together in the end. So aligning incentives, I do think the CCBC really focuses a lot on this and gives a lot of a push to create these uh called you know designated service organizations that are collaborating. We can actually use the money to fund other organizations if we want. So I think there's a movement in that, but the the the still the misaligned incentives is one of the biggest barriers by hand by by just a landslide. Um, which is why like when teen talks about like the the your the system that they've created, it's that's great. And it's it's the kind of alignment that you want in a health system. You know, you want that alignment to happen across the span. Um, but the the country is is is behind in this piece in particular. So the silos occur, right? Referrals without a warm handoff occur, the misaligned incentives occur, you know, hospital saves money, we don't get any of it, uh then we don't get any rate increases. Uh so you know, all of it is still getting played around. So the Canada Coalition's domains, you know, they're really an important framework to have the conversation and policy. I am hopeful with CMS that this can continue to move forward to fund these kind of alignments.
SPEAKER_01And I think what Teen said earlier was really important too. We're doing a lot of things that are affecting metrics for hospitals and for different systems. We are saving them money, but it is how do you how do you showcase that across the board? How do you have credit where you know credit is due across the system? And how do you show that in the shared metrics? I think that's a really important point. Of we've got a lot of data. Are we tracking the same things? Are we all understanding success in the same way?
Unexpected Challenges Data And Workforce
SPEAKER_05Speaking of success, let me ask all of you. I'm gonna ask each of you to be a little vulnerable in that. Um, can you talk about a challenge that each of you faced in this integrated care model that maybe you didn't see, maybe you didn't anticipate. And then once it came to the fore, how did you solve it?
SPEAKER_01I think that we're we're measuring, again, like we were just talking about, a lot of different metrics across a lot of different programs. And a challenge that we had was we have a lot of data and a lot of people doing good work, but we didn't have it in one system. And over the last couple of years, we have transitioned all of our clinical programs into one EHR. So now we have a single electronic health record and we have the same EMAR across our system as well. So now people have access in real time to patient information across our system of care. And I think that as we continue to build out our data warehouse, we're able to see operational data, clinical data, workforce data all together. But I think the challenge still is how do we make that data as easy as possible to use and to actually look at quickly and utilize to make a decision? So I think we've made a lot of great strides in having actionable data, but we're still continuing to build that.
SPEAKER_03People, organization, and leaders and their teams that get this matter. And there's not that many of us. I just want to say that that even yes, there's CCBHCs that are being funded, uh, but that you still have another system, the ID autism system is lagging behind. It's not a healthcare system yet. Uh so we it's there's few of us like I'm boundless and wood system of care that are in the healthcare space when it comes to ID autism. So we have a little further to go, I think, there, than a traditional behavioral health system that has been, you know, I would say, you know, around for a long time, but we're finally here, integrating, you know, primary and behavioral health care. But maybe Dr. Mousineer can say a little bit more about how we've done it because uh, you know, we've we've had a lot of moments together and lessons together over the years.
SPEAKER_02I mean, it takes a bit really to build that integrated care model because you need that right partner, right person to build that integrated network, or creating that interdisciplinary team. What Katie mentioned is something that I still struggle with. We need an integrated in EHR, but the integrated value-based model as well. How we created is creating that really a model where the whole thing revolves around a person and the family. Person and family-centered model is really important for us. You know, there is a lot of buy-in from other providers and specialists once they see that the outcome is really the quality of the care that we are improving and decreased number of ER visits and the crisis and the transitions are smoother. You know, so we need to educate all our partners on really this is this is the model that's going to work for this population. One of the things we have done really and continue to evolve at wood system of care is bringing those specialists back into that primary care network so that the families don't have to go to a neurologist, a GI person, and then we are trying to coordinate all that. We are happy to report that you know that we are actually bringing the genetics into the mix as well and building a long-term neurology care, more looking at what is the population care is going to look like once they transition from adulthood into the old age. So you know they are living longer under chronic medical conditions. So we are thinking ahead, what is it going to look like, the whole lifespan care?
SPEAKER_05Dimitri, have not a challenge for you that you didn't see coming.
SPEAKER_04Yeah. Workforce development engine by far, it's still my biggest problem. So this is a big issue for us. And we have a very complex model, just like Woods and others that like like that are here in this call, and to find people that we can um, you know, go through orientation, onboarding, year one learning, ongoing mastery, and understand all the things we're doing and how they align to help the client and stay around long enough to learn the job is our biggest problem. And you know, we lose half the people in the first 18 months, half of our staff, 50% are of it. It's horrible. We're really working hard to try to figure this out. We actually stabilized our leadership team. We've been we've been investing with an organization called Tandem Partners. Uh Margaret Wilson's been our leadership and executive coach for the past seven years, and that has been really the the I always say it's a special sauce in our burger. Uh and that has really helped us overcome the workforce development problems we're having because my leadership team is extremely strong and engaging, and the where we are today would not have happened without them, trying to figure out what is the what is that sauce for the rest of this workforce that's coming in, right? That are brand new or they've changed jobs and they've done other jobs and or worked in organizations that do not have the same complexity we have, or do not have the same infrastructure that we have, where they have to really understand a more complex model to help our clients. So we are we're I'm actually trying to find right now someone to really guide us through like what is orientation onboarding year one and ongoing mastery look like? How do we get people to understand all these extremely important evidence-based practices?
SPEAKER_05Let me end with a
Whole Person Care Needs Ecosystems
SPEAKER_05final question. Uh, we're gonna do a ninth grade fill in the blank here for all of you. Well, I should say finish the sentence. How about this?
SPEAKER_01The future of whole person care belongs to organizations that it belongs to organizations who understand that success is not about saying, did we meet our metrics, but did patients actually experience integrated care? And are they living more boundless lives because of it?
SPEAKER_03Working together to transform, always adapting, is building trust, uh, and again, having the person in the center with a shared common purpose. And I would also say collaborating, innovating, having an innovative spirit and work across traditional boundaries and always looking at, you know, what can we do better and what's out there, what's on the horizon, going back to how can we serve that individual and that family that might be involved in that individual's lives.
SPEAKER_02I think Dean mentioned it all as a treating uh clinician. I want to put that family and the individual in the center and building that integrated whole person care around the person and also creating those stronger partnerships so we are all working together and keep innovating, you know, adding more, adding more services to the integrated care.
SPEAKER_05All right, Dimitri, you're batting cleanup here. The future of organization, the future of whole person care belongs to organizations that I'm really hesitant to even answer it on this podcast, but I'm gonna say it.
SPEAKER_04Um that build local ecosystems, not empires. It's very hard to have a large health system and have a local ecosystem. Now large organizations can do it, they can invest to do that. And there are cases that that does happen. But there's a tendency for that not to happen. So I really think if whole person care is really going to be successful, it has to be connected into the community, has in the local community, they understand who they're serving, that there's infrastructure in place to serve the community in a way that's very helpful, and they fund the organization and make sure that the plumbing also works, right? That the program has everything in place and the infrastructure in place to make a successful intervention for the community.
SPEAKER_05Just a great conversation here. Again, my thanks to all of our guests for digging into a lot of details here and providing executives out there with real authenticity, uh, some vulnerability, and real answers to a lot of pressing questions. So, Katie, Dimitri, Teen, and Telija, thank you again for joining us. Thank you.
SPEAKER_02Thank you, Scott. Thank you
Mission Moment Erica’s Dental Breakthrough
SPEAKER_02for having us.
SPEAKER_05It is time now for our mission moment. And for that, I want you to meet my new friend Timmy. Hi, Timmy. Hello. Tell us about your mission moment.
SPEAKER_00So I wanted to talk about um who we got consent from, our friend Erica. Um, when she first came to Boundless, um, she wasn't able to complete appointment, dental appointment. And so beforehand, too, she's only received sedation appointments. So she's never had a dental appointment without sedation. And so coming in, we were aware of that. And so we decided to do skill building with her. Um, and for her, it was very hard to sit in a dental chair or medical chair or any chair related to a doctor's office. And so we practiced those skills to be able to sit in a dental chair. And so then after that practice that we had, she was able to not only sit in a dental chair, but she has also completed her first ever cleaning by herself and then also took a panoramic x-ray, which is the one that goes around your head. And she was able to do that for the first time in 20 years. She is 30, she was 32 at the time. And so she has been able to do that. And then it also correlated because dental skill building is not just for dental as well. It could be transferred over to other areas as well. And so we were able to actually have her complete a medical appointment by herself, or she sat in the chair by herself, was able to do a full medical appointment. And it really helped because mom had never experienced that before either, seeing that. And what's even great, I'm gonna even push out further, is she actually went to a podiatrist and was able to sit in the chair the entire time for a podiatrist as well, based on what we did in dental skill building. So she has shown great improvement and has been able to complete all of her medical appointments by herself with her wanting to do it. That was the key to this. So that's my mission moment is definitely definitely Erica's ability to now be able to do appointments by herself because of what we did together.
SPEAKER_05This is improving her health and and seriously could be adding years to her life moving forward, right? Exactly. That's exactly what that is. This is amazing. Um, Timmy, what a great mission moment. Thank you for sharing her story. Thank you. I appreciate sharing the story with you. That was really, really impactful. And it gets to exactly what we're talking about in terms of whole person care. Emphasis
Final Takeaways And Sign-Off
SPEAKER_05on care. My thanks to our other guests as well for breaking down those challenges and also providing answers when we are talking about integrated whole person care. This is the Nonprofit Leader's Guide brought to you by Boundless. Until the next time, I'm Scott Light.